Provider Demographics
NPI:1477113983
Name:JOHNSON, CHANTAL D
Entity Type:Individual
Prefix:
First Name:CHANTAL
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 HAMPTON FOREST DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-2572
Mailing Address - Country:US
Mailing Address - Phone:803-651-8834
Mailing Address - Fax:
Practice Address - Street 1:302 HAMPTON FOREST DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-2572
Practice Address - Country:US
Practice Address - Phone:803-651-8834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC116931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical